Citation Nr: 1414580
Decision Date: 04/03/14 Archive Date: 04/11/14
DOCKET NO. 12-02 136 ) DATE
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On appeal from the
Department of Veterans Affairs Regional Office in Cleveland, Ohio
THE ISSUE
Entitlement to a rating in excess of 10 percent for posttraumatic stress disorder (PTSD).
WITNESS AT HEARING ON APPEAL
The Veteran
ATTORNEY FOR THE BOARD
Megan C. Kral, Associate Counsel
INTRODUCTION
The Veteran served on active duty from April 1965 to March 1967.
This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. In February 2013, a videoconference hearing was held before the undersigned. A transcript of the hearing is associated with the Veteran's claims file.
The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action on his part is required.
REMAND
The Veteran was most recently provided a VA examination to determine the severity his service-connected PTSD in January 2011; more than three years ago. On examination the Veteran reported anxiety attacks occurring once every six months. During the February 2013 hearing, the Veteran testified that anxiety attacks were triggered two to three times per month. This testimony is an indication of worsening symptomology since the January 2011 examination. In light of the length of the intervening period since the January 2011 examination and the allegation of worsening, a contemporaneous examination is necessary. Weggenmann v. Brown, 5 Vet. App. 281 (1993).
Additionally, the Veteran testified that he received treatment at the VA medical center as recently as 2013. Only minimal records (from June 2011 to September 2011) of such treatment are of record. The Statement of the Case indicates that records from the VA Medical Center in Cleveland, Ohio dated from November 2007 to September 2011 were reviewed. However, only records from June 2011 to September 2011 are actually in the file. As VA treatment records may contain pertinent information, and are constructively of record, they must be sought. Bell v. Derwinski, 2 Vet. App. 611 (1992).
Accordingly, the case is REMANDED for the following action:
1. The RO should obtain records of all VA treatment the Veteran has received from the VA Medical Center in Cleveland, Ohio, and all associated outpatient clinics, including the clinic in Akron, Ohio, dated from November 2007 to June 2011, and from September 2011 to the present. All attempts to obtain these records must be documented in the claims file.
2. The RO should then arrange for a psychiatric evaluation of the Veteran to determine the current severity of his PTSD. The entire record must be reviewed by the examiner in conjunction with the examination. The examiner must provide accurate and fully descriptive assessments of all psychiatric symptoms, conduct a mental status examination, enter a complete multi-axial evaluation, and assign a Global Assessment of Functioning (GAF) score, together with an explanation of what the score represents in terms of the Veteran's psychological, social, and occupational functioning.
A complete rationale for all opinions must be provided.
3. The RO must notify the Veteran that it is his responsibility to report for the scheduled examination and to cooperate in the development of the claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. § 3.655(a) (2013)
4. The RO should then review the record and readjudicate this claim. If it remains denied, the RO should issue an appropriate supplemental statement of the case and afford the Veteran the opportunity to respond. The case should then be returned to the Board, if in order, for further review.
The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2013).
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ROBERT C. SCHARNBERGER
Veterans Law Judge, Board of Veterans' Appeals
Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2013).